So your period is missing or comes every now and again (3 months here, 4 months there...)
Not all of us are text book 28-day cyclers - there are people who have menstrual cycles 26 days long, 32 days, 34 days and people who experience longer cycles at 42 days +
The latter is what we would call irregular. Ideally, a menstrual cycle is around on average 26-34 days in length. Shorter? Investigate. Longer? Investigate. All over the place? Investigate. Missing? Investigate.
Briefly, before we get stuck in to missing periods - let's quickly catch up on what your menstrual cycle is and does!
The menstrual cycle is made up of 4 phases:
bleed (progesterone drops to signal no implantation - menstruation occurs; the endometrium is shed)
follicular phase (the first half of your cycle where oestrogen is rising, the ovarian follicles are maturing in preparation for ovulation).
ovulation (egg released from ovaries; hormones involved are LH + FSH; LH surges to stimulate the egg release).
luteal phase (second half of the menstrual cycle, where progesterone is rising to prepare the uterus for implantation of embryo).
It's around day 9-11 (ish) you will also get a surge of testosterone in time for ovulation - helping to get a libido boost before ovulation.
So as you can see, hormones are little signallers - they are telling the body what to do and what to prepare for. This is why in clinical practice, if you come to see me for an issue with fertility, absent periods, irregular etc - we check out your hormones AND on specific days of the month.
What causes irregular periods?
Firstly, an irregular period is one that comes some months "on time", and other months, late, early OR absent, and some people will experience anovulatory phases which means no ovulation (no egg was released) which can occur for months or years. Some people can lose their period altogether, this is called Amenorrhea. When a period is absent for longer than 3 months.
If the period is missing altogether, the tests considered to investigate why are as follows:
Prolactin - helping to understand if levels are too high, interfering with your FSH levels, affecting ovulation.
FSH + LH + E2 (oestradiol; a type of oestrogen). Investigating if brain hormones FSH + LH are talking to your ovaries as we need them to and E2 to check if there is response from LH + FSH. Higher than normal levels of FSH can indicate primary ovarian insufficiency (POI) alongside low E2; meaning your ovaries are not functioning optimally.
Thyroid - If your thyroid is not functioning properly, this can impact your menstrual cycle and thus, fertility. A full thyroid panel will be helpful not just your TSH as this does not tell us enough. We would look at TSH + T3, T4, rT3, anti-TPO. If you already know you have Hyperthyroidism or Hypothyroidism, chances are this is impacting your missing period.
Adrenals - High levels of cortisol can impact progesterone production.
Testosterone - total and free. High levels of testosterone (which we see in some people who have PCOS) aka hyper-androgens, can suppress ovulation.
Taking in to account all of the above, considering if it is PCOS and having extra lab work done if this is a high possibility, perhaps an internal ultrasound to investigate the ovaries. Lab work in addition to testosterone here would not be diagnostic, but would be helpful to rule PCOS out.
Why could a period be missing? (Amenorrhea)
Ovarian dysfunction - PCOS, POI, Addisons Disease and some people in perimenopause close to menopause.
Hypothalamic Amenorrhea (HA) - this is an extremely common reason and one I see in clinic all the time. It is not a disease or a disorder, but a very normal physiological reaction of the brain and body. When the energy in does not meet what energy is going out, the hypothalamus is not going to prioritise ovulation when it believes you're in survival mode. We would need to ensure enough calories in, stress is being managed and there is a high level of consistency. Many people who over-exercise so happen to under-fuel, and the result is HA.
Functional Hypothalamic Amenorrhea - hormone GnRH is reduced at hypothalamus - GnRH is required for FSH + LH production at pituitary. LH is needed for ovulation. So this cascade can halt ovulation when GnRH is being misfired.
Pituitary Dysfunction - often due to higher than normal levels of prolactin. The hormone which breastfeeding parents produce at high levels for milk production. This can also occur in those not breastfeeding and cause hyperprolactinemia.
Low Thyroid Function; Hypothyroidism - an under-diagnosed condition, this can cause amenorrhea. This is why having a thyroid panel is important to rule out thyroid function (or dysfunction).
When there is a dysfunction occurring in your body - think of it this way:
A crime is being committed (in your body).
We need to investigate.
This takes time - no crime is solved in 15 minutes.
In my clinic we discuss your signs, symptoms, history, familial history, current health status (looking at different systems of the body), lifestyle factors (work, hobbies, choices), dietary habits and choices, potential deficiencies etc. THEN we order the appropriate testing depending on what is going on for you.
XX Yours in Optimal Health
BHSc Nut Med
Céline Bouchard and others, Use of Oral Contraceptive Pills and Vulvar Vestibulitis: A Case-Control Study, American Journal of Epidemiology, Volume 156, Issue 3, 1 August 2002, Pages 254–261